Form Soc 155c - Voluntary Placement Agreement Parent/agency (Indian Child)
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2STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
VOLUNTARY PLACEMENT AGREEMENT
COMPLETE IN DUPLICATE:
PARENT/AGENCY
One copy to:
Parents of Guardian
(Indian Child)
Child’s Social Service Record
CASE NAME
CASE NUMBER
I request that the ________________________ County Welfare Department place my child __________________________________
___________________________________________________________________________________________________________
in a licensed/certified foster care facility. My reason for the request is_____________________________________________________
___________________________________________________________________________________________________________
I know that voluntary foster care is limited to six months and that my child will be returned to me by _____________________________
(DATE)
The Agency agrees to:
1. Place my child in accordance with the provisions of the Indian Child Welfare Act (25 United States Code 9001 et. seq.)
2. Arrange for care of my child in a licensed/certified foster care facility.
3. Select the home with the participation of me and my child.
4. Supervise my child while in foster care.
5. Arrange for services which will help my child return home, discuss those services with me and list them in a written service
plan.
6. Arrange for medical care. Notify me of emergency medical care or hospitalization of my child.
7. Notify me if a change in foster care facility is necessary.
8. Provide a grievance procedure.
9. Carry out legal consent provisions on behalf of my child in this agreement.
Recognizing my responsibility for the care and welfare of my child, I agree to:
1. Assist the Welfare Department in determining my financial responsibility for the care of my child while in foster care.
2. Keep the Agency advised at all times of my address and telephone number.
3. Visit my child as per arrangement with the placement agency.
4. Allow the Agency to move my child, if necessary, to another foster care facility.
5. My child’s participation in the activities planned by the placing agency and/or foster care facility, including trips within the state.
6. Carry out my part of the service plan.
7. Discuss with the Agency placement problems of my child.
8. Give reasonable notice to the placement worker if I plan to move my child, although I retain the right to withdraw my consent to
foster care placement at any time.
9. Authorize the foster parent to give consent on behalf of my child except as prohibited by me in the agreement.
I agree the person providing care for my child may give legal consent on behalf of my child except as limited in the following statement.
(if more space is needed use the reverse side of this form).
THE UNDERSIGNED HAS CUSTODY AND CONTROL OF THE CHILD
CERTIFICATION
SIGNATURE OF PARENT
SIGNATURE OF WITNESS TO PARENT
The ter ms and consequences of the
voluntary signing of consent were fully
explained to the Indian parent by the
SIGNATURE OF PARENT
SIGNED IN PRESENCE OF
Agency representative in my presence, in
a language understood by the parent. The
right to withdraw consent at any time was
ADDRESS
REPRESENTATIVE, COUNTY WELFARE DEPARTMENT
also explained.
SIGNATURE OF JUDGE
ADDRESS
SUPERIOR COURT
HOME PHONE
ALTERNATE PHONE
DATE SIGNED
PHONE
DATE SIGNED
PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE
SOC 155C (1/00)
Required Form
No Substitute Permitted
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